Smoking in pregnancy is a key factor for sudden infant death among Māori

AIM

To examine the sudden unexpected death in infancy (SUDI) disparity between Māori and non-Māori in New Zealand.

METHODS

A nationwide prospective case-control study ran from March 2012 to February 2015. Exposure to established SUDI risk factors was analysed to investigate the disparity experienced by Māori. Infant ethnicity was based on mother's ethnicity. Māori ethnicity was prioritised. Non-Māori includes Pacific, Asian, NZ European and Other.

RESULTS

There were 137 cases and 649 controls. The Māori SUDI rate was 1.41/1000 live births compared to 0.53/1000 for non-Māori. Parents/caregivers of 132 cases (96%) and 258 controls (40%) were interviewed. Smoking in pregnancy was associated with an equally increased SUDI risk for Māori (adjusted OR = 8.11, 95% CI = 2.64, 24.93) and non-Māori (aOR = 5.09, 95% CI = 1.79, 14.47), as was bed-sharing (aOR = 3.66, 95% CI = 1.49, 9.00 vs aOR = 11.20, 95% CI = 3.46, 36.29). Bed-sharing prevalence was similar; however, more Māori controls smoked during pregnancy (46.7%) than non-Māori (22.8%). The main contributor relating to increased SUDI risk for Māori/non-Māori infants is the combination of smoking in pregnancy and bed sharing.

CONCLUSION

The association between known SUDI risk factors, including bed sharing and/or smoking in pregnancy and SUDI risk, is the same regardless of ethnicity. Māori infants are exposed more frequently to both behaviours because of the higher Māori smoking rate.

Silicon-organic hybrid (SOH) frequency comb sources for terabit/s data transmission

We demonstrate frequency comb sources based on silicon-organic hybrid (SOH) electro-optic modulators. Frequency combs with line spacings of 25 GHz and 40 GHz are generated, featuring flat-top spectra with less than 2 dB power variations over up to 7 lines. The combs are used for WDM data transmission at terabit/s data rates and distances of up to 300 km.

Surveillance of Australian workplace Based Respiratory Events (SABRE) in New South Wales

BACKGROUND

The Surveillance of Australian workplace Based Respiratory Events (SABRE) New South Wales (NSW) scheme is a voluntary notification scheme established to determine the incidence of occupational lung diseases in NSW Australia.

AIMS

Data presented in this paper summarize the last 7 years of reporting to SABRE (June 2001 to December 2008).

METHODS

Every 2 months, participating occupational physicians, respiratory physicians and general practitioners (accredited by the NSW WorkCover Authority) reported new cases of occupational lung disease seen in their practices. Data collected include gender, age, causal agent and the occupations and industries believed responsible. Estimated incidence was calculated for each disease.

RESULTS

Three thousand six hundred and fifty-four cases were notified to the scheme, consisting of 3856 diagnoses. Most of the cases were males (76%). Pleural plaques [1218 (28%)] were the most frequently reported condition, followed by mesothelioma [919 (24%)]. Silicosis [90 (2%)] and occupational asthma [OA; 89 (2%)] were the most frequently reported non-asbestos-related diseases. Estimated rates for mesothelioma, diffuse pleural thickening (DPT) and OA were 83, 83 and 5 cases per million employed males per year, respectively. Trades such as carpenters and electricians associated with the building industry, electricity supply and asbestos product manufacture were the most common occupations and industries reported.

CONCLUSIONS

Asbestos-related diseases are the most frequently reported conditions to SABRE NSW. The very low incidence of OA for NSW most likely reflects under-diagnosis as well as under-reporting. Occupational lung disease is still occurring in NSW despite current preventative strategies. The SABRE scheme currently provides the only available information in this area.

The biology and prognostic value of lymphatic vessel density (LD) and lymphatic invasion (LI) in regression in melanoma

9017

Background: Regression in melanoma is characterized by increased vascularity, lymphocytic infiltrate and fibroplasia in the papillary dermis, accompanied by the absence (complete regression, CoR) or presence (partial regression, PaR) of melanoma cells in the epidermis. The prognostic value of regression is controversial. We noticed that LD and LI were increased in the areas of regression (AR) or areas with brisk lymphocytic infiltration (AB). Our goal was to clarify the prognostic value of regression in melanoma. Methods: Dual immunohistochemical staining was done using antibodies to podoplanin (lymphatic vessels) and S100 (melanoma cells) on paraffin tissues from 321 patients with vertical growth phase (VGP) primary melanomas who had 10 years or more of follow-up. LD in AR (both CoR and PaR) was compared with that of normal dermis adjacent and distant, as well as LD in the AB. LI in these areas was also scored. Unadjusted and adjusted hazard rates were obtained from univariate and multivariate Cox models for time to melanoma-specific death using established melanoma prognostic factors. Results: 116 patients (36%) had regression: 75 CoR (23%) and 41 PaR (13%). LD significantly decreased stepwise from CoR (mean ± se, 23.7 ± 2.7) to PaR (15.5 ± 1.1), adjacent normal dermis (7.3 ± 0.28) and distant normal dermis (5.4±0.31) and it was significantly elevated in the AB (18.5±0.78). Melanomas with CoR had the highest percentage of LI in both AR and AB. In addition, the percentage of LI in AB was highest for men and for those with VGP tumor infiltrating lymphocytes (TILs). Both high LD in AR and more LI in AB were associated with poor prognosis (p=0.004 and p=0.002, respectively). Six factors were significant in the final multivariate model: LI in AB (HR=2.3), LD in AR (HR=1.04), thickness (HR=1.44), axial (HR=7.7), ulceration (HR=2.5) and no VGP TILs (HR=2.8). Conclusions: AR and AB were associated with increased LD and higher incidence of LI in primary melanomas. LD and LI in AR or AB are independent prognostic factors. Our data suggest that the effects of regression on prognosis are mediated at least in part through lymphangiogenesis and LI.

No significant financial relationships to disclose.

Ki67 as a prognostic biomarker for patients with vertical growth phase (VGP) melanomas

9043

Background: In VGP melanomas proliferation is reflected in dermal mitotic figures (“mitogenic” VGP) and/or tumor cell nests larger than any epidermal nest. An alternative to mitotic rate (MR) to characterize cell proliferation is the expression of Ki67 protein. Since Ki67 is expressed in all phases of the cell cycle except G0, it is potentially a more robust biomarker for proliferation and prognosis than mitoses. Methods: To test the hypothesis that Ki67 would replace MR as a prognostic factor, we did a retrospective cohort study of 432 patients with Stage I/II primary VGP melanomas who had at least 10 years of follow up. Tissue sections were stained using the monoclonal antibody MIB-1 to Ki67 and the % of positive melanoma cells were evaluated by two readers. ROC curves for Ki67 and MR were computed. Predicted probabilities (PP) of 10-year melanoma-specific death were computed from 3 multivariate logistic regression models, one for each biomarker (Models 1 and 2) and one with both (Model 3), controlling for established melanoma prognostic factors (thickness, gender, anatomic site, ulceration, regression and tumor infiltrating lymphocytes), and compared. Cross-validation was used to assess differences between using Ki67 and using MR including the differences in PP, Brier scores and the misclassification rates. A decision curve analysis was done to assess the clinical net benefit of the two. Results: The areas under the ROC curve (AUCs) for Ki67 and MR, both continuous factors, were 0.69 and 0.79, respectively. In the multivariate analysis, Ki67 expression was significant in Model 1 (OR=1.03, 95% CI: 1.01–1.05), mitotic rate was not significant in Model 2 (1.05, 0.99–1.1), and only Ki67 was significant in Model 3 (1.03, 1.01–1.05). The AUCs for the three models were 0.84, 0.84, and 0.85, respectively. Based on cross-validation, there was no difference between the two biomarkers in PP, Brier scores, or misclassification rates. The decision cost analysis demonstrated the same net benefit for the two. Conclusions: A prospective study needs to be conducted to confirm that Ki67 and MR are equivalent.

No significant financial relationships to disclose.

The prognostic significance of lymphatic invasion in primary melanoma

9050

Background: Lymphatic invasion (LI) is an under-observed phenomenon in primary malignancies that can be better detected by immunostaining and that may associate with prognosis. In this study we sought to test the hypothesis that LI was associated with melanoma-specific survival (MSS) and was an independent prognostic factor. Methods: This study included 277 patients with stage I/II melanomas in vertical growth phase (VGP) who had at least 10 years of follow up. The log-rank test was used to test the study hypothesis - 72 melanoma-specific deaths were needed for 80% power to detect an odds ratio of 2.1. Paraffin sections were stained with antibodies to podoplanin (lymphatic vessels) and S-100 (melanoma cells) to identify LI. Univariate and multivariate Cox models were used to evaluate the prognostic significance of LI. An independent cohort of 106 similar patients was used for validation of the 10-year MSS rates. Results: LI was observed in 44.5% (95% CI: 38.6% - 50.4%) of the melanomas and its presence was significantly associated with thickness, mitotic rate, gender, age, and ulceration (U). The Kaplan-Meier survival curves for those with and without LI were significantly different (log-rank test p=0.022). The final multivariate model for time to MSD identified 4 independent prognostic factors: thickness (HR=1.5, p<0.001), U (HR=2.2 p=0.013), site (HR=3.9, p<0.001) and LI (HR=1.9, p=0.015). These factors were used to define a prognostic tree with 5 risk groups defined by melanomas that were thin (≤1.0mm) with no LI or U; thin with LI but no U; 1–3mm with no U; 1–3mm with U; and >3mm. Respectively, MSS rates were 100%, 88.6%, 77%, 48% and 42%. In the validation set, observed 10-year MSS rates in each risk group were not significantly different from those predicted from the survival curves for the tree-based risk groups. Conclusions: LI is an independent prognostic factor for MSS. Among patients with thin melanomas without U the 10-year MSS was lower for those patients with LI (89%, 95% CI=78% - 99%; n=41) compared to those without (100%, n=78). LI is an important prognostic factor that needs further validation in a population of patients from the sentinel node biopsy era.

No significant financial relationships to disclose.

Serum vitamin D levels, VDR, and survival from melanoma

9016

Background: Vitamin D has pleiotropic effects, which may moderate the interaction between patients and their tumors. Two studies were carried out to test the hypothesis that higher vitamin D levels reduce the risk of relapse from melanoma. Methods: A pilot retrospective case-control study in 271 melanoma patients suggested that vitamin D may protect against recurrence of melanoma. We then tested these findings in a survival analysis in a cohort of 872 cases recruited to the Leeds Melanoma Cohort (median follow up of 4.7 years). Results: Pilot study Results suggested that taking vitamin D reduced the risk of relapse from melanoma (OR 0.6, 95% CI: 0.4, 1.1). Non-relapsers had higher mean 25-dihydroxyvitamin D3 levels than relapsers (49 nmol/L compared with 46, p=0.3). Cohort study Higher 25-dihydroxyvitamin D3 levels were associated with lower Breslow thickness at diagnosis and were independently protective of relapse and death: hazard ratio (HR) for relapse free survival (RFS) 0.76, 95% CI: (0.64, 0.96), for a 20nmol/L increase in serum level. There was evidence of interaction between the vitamin D receptor (VDR) BsmI genotype and serum 25-dihydroxyvitamin D3 levels on RFS. Conclusions: The pilot study provided preliminary evidence for a role for vitamin D in outcome from melanoma. The cohort study provided further evidence that higher 25-dihydroxyvitamin D3 levels, at diagnosis, were associated both with thinner tumors and better survival, independent of Breslow thickness, from melanoma. Melanoma patients should avoid vitamin D deficiency. Further studies are needed to establish optimal serum levels for melanoma patients.

No significant financial relationships to disclose.

Inhibition of COX-2 with NS-398 decreases colon cancer cell motility through blocking epidermal growth factor receptor transactivation: possibilities for combination therapy

The use of non-steroidal anti-inflammatory drugs has proved of great interest in the prevention and treatment of colorectal cancer, although their precise mechanisms of action remain unclear. Overexpression of cyclooxygenase-2 (COX-2) and subsequent prostaglandin production promote metastasis and have been shown to increase cell motility in vitro.

OBJECTIVE

We have aimed to elucidate whether specific inhibition of COX-2 with NS-398 (NS-398 is a selective inhibitor of COX-2) would be able to inhibit motility of colorectal cancer cells and whether this was modulated through epidermal growth factor receptor (EGFR) transactivation.

MATERIALS AND METHODS

A transwell filter assay was used to study cell motility. Expression of COX-2, EGFR phosphorylation and prostaglandin E(2) (PGE(2)) receptors were assessed by Western blot analysis and reverse transcriptase-polymerase chain reaction. PGE(2) concentrations after NS-398 treatment were estimated by enzyme immunoassay.

RESULTS

Treatment with NS-398 significantly reduced PGE(2) levels and reduced cell migration in the HT29 and HCA7 colorectal carcinoma cell lines and this effect was rescued by addition of PGE(2). Furthermore, specific inhibition of COX-2 with NS-398 reduced EGFR phosphorylation in colorectal cancer cells. Direct inhibition of EGFR activity with AG1478 reduced PGE(2)-stimulated motility, clearly demonstrating that PGE(2 )acts via the EGFR-signalling pathway. The novel combination of NS-398 and AG1478 dramatically reduced migration of colorectal cancer cells.

CONCLUSION

The data presented indicate that the use of NS-398 in chemoprevention and adjuvant therapy for colorectal cancer may work in part, through the inhibition of cell motility. Furthermore, our data suggest that the combined use of non-steroidal anti-inflammatory drugs with EGFR antagonists could be explored further for future use in the clinic.

The evolution of senescence in natural populations of guppies (Poecilia reticulata): a comparative approach

Model organisms like Drosophila melanogaster or Caenorhabditis elegans have revealed genes that influence senescence and the evolvability of senescence. We are interested instead in evaluating why and how senescence evolves in natural populations. To do so, we are taking the ecological geneticist's perspective of comparing natural populations that differ in factors that are predicted to influence the evolution of senescence and are evaluating whether senescence has evolved in the predicted fashion. We are also manipulating the environment to evaluate more directly the evolution of senescence. Guppies (Poecilia reticulata) are found in streams throughout the Northern Range mountains of Trinidad. Natural populations experience large differences in mortality rate as a consequence of the predators with which they co-occur. We have already shown, both with comparative studies and manipulations of the distribution of guppies and their predators, that the early life history evolves very rapidly in response to these differences in mortality. For example, high adult mortality rates select for individuals that develop more rapidly, produce their first litter of young at an earlier age, and devote more of their available resources to reproduction for the remainder of their lives. These changes were predicted by independently derived theory. Aspects of this same theory also predict how the late life history and senescence should evolve. Specifically, theory predicts that the populations that experience low mortality rates should also experience delayed senescence and longer life spans relative to those that experience high mortality rates. We are currently evaluating these predictions with representatives from two high-predation and two low-predation environments. Our presentation will focus on our pilot study, which evaluated life span, lifetime reproduction, and the patterns of aging in our laboratory populations. We will also report on the progress in our ongoing comparative studies of senescence in natural populations.

Delays in the investigation of allegations of child sexual abuse in the Wellington city district 1995-1996: a retrospective study

AIMS

To determine the duration of the statutory investigation process after referral of alleged chid sexual abuse and to assess which components of this process are most prone to delay.

METHODS

Retrospective review of police, Child Youth and Family (CYF) and medical records for 123 young persons <17 years old for whom a referral regarding alleged sexual abuse was made to the Wellington Serious Abuse Team from January 1995 to December 1996.

RESULTS

There were 82 (66.7%) females and 41 (33.3%) males referred. Maori and Pacific Island children were over-represented in the sample. The median time from referral to evidential interview or diagnostic interview was 47 days. This period was longer for children <5 years of age (66 days) compared with children > or =5 years of age (45.5 days), although this difference was not statistically significant. Although 53.3% of children alleged genital contact, only 26% were referred for a medical assessment. The time from initiation of investigation to completion was a median of 141 days. Reasons for delay were difficult to delineate but appeared to relate to inadequate staffing.

CONCLUSIONS

There is an unreasonable delay in the investigation of alleged child sexual abuse. This is particularly concerning in younger children.

Isolation of the melanoma-associated antigen p23 using antibody phage display

The general responsiveness of human melanoma to immunotherapy has been well established, but active immunotherapy of melanoma has been hampered by insufficient information on the immunogenicity of melanoma-associated Ags in patients. In this study, we isolated a recombinant phage-Fab clone (A10-5) from a phage-Fab library derived from the B cells of a melanoma patient in remission after immunotherapy. Purified A10-5 Fab bound at high levels to cultured melanoma cell lines and to tissue sections of metastatic and vertical growth phase primary melanoma, but not to radial growth phase primary melanoma, nevi, or normal skin. A10-5 Fab bound to both the surface and the cytoplasm of cultured melanoma cells, but only to the cytoplasm of cultured fibroblasts. Western blot analysis revealed A10-5 Fab reactivity with a 33- and a 23-kDa glycoprotein under nonreducing conditions, and with a 23-kDa protein only under reducing conditions. A cDNA with an open reading frame predicted to encode a 23-kDa protein was cloned by screening a melanoma cell cDNA library with A10-5 Fab. This protein (p23) is the human homologue of the murine tumor transplantation Ag P198 that interacts with the cytoplasmic domain of ErbB-3 expressed by melanoma cells. Thus, the Ab phage display method has identified a novel, stage-specific melanoma-associated Ag that may have therapeutic and diagnostic value.

Split gene origin and periodic introns

The introns-early view has been challenged for several genes; prominent instances are triose phosphate isomerase (TPI), aldolase, pyruvate kinase (PK), alcohol dehydrogenase (ADH), glyceraldehyde-3-phosphate dehydrogenase (GAPDH) and myosin heavy chain. While some of their introns appear to be phylogenetically ancient and/or to delineate exons corresponding to protein modules, a considerable number seemingly do not. But it is argued here that many of these anomalous introns are periodic, that is, relics of internal sequence repetitions within the ancestral gene. Some of these periodic-intron patterns are shared between related genes, as in the alphabeta -barrels of TPI, aldolase and PK, or the Rossmann nucleotide-binding domain common to PK, ADH and GAPDH. This is further evidence for the ancestral status of these introns. The myosin heavy chain C-terminal rod region is paradoxical in that its sequence is clearly periodic but its intron placements are not; however, they exhibit a remarkable coherence of intron translational phases, suggesting that these introns may also have originally had a periodic arrangement now obscured by intron slipping.

Sexual development in a two-year-old boy induced by topical exposure to testosterone

Virilization, including penile enlargement and growth of pubic hair and facial acne, developed in a 2-year-old boy over a period of months. This sexual development was induced by incidental and unintentional dermal exposure to a testosterone cream that was applied to his father's arm and back as a part of body building regimen. Except for penile size, the other signs of virilization diminished several months after the exposure was discontinued.

Tumor progression, early diagnosis and prognosis of melanoma

Primary melanomas evolve from melanocytes or from precursor lesions through two stages: the radial and vertical growth phases. The radial growth phase may be in situ or microinvasive, but is a non-tumorigenic neoplastic process, while the vertical growth phase is tumorigenic. The prognosis in radial growth phase is excellent irrespective of thickness or other variables. Curable radial growth phase melanomas can be recognized by surveillance of patients identified by screening for risk markers which include dysplastic nevi, common nevi, freckles, and other indicators of chronic or acute sun exposure or sun sensitivity. The prognosis in vertical growth phase depends on attributes of the tumor and of the host. The tumor mitotic rate, the presence of host tumor-infiltrating lymphocytes (TIL) within the vertical growth phase, and tumor thickness are the most powerful predictors of survival. New prognostic attributes are needed not only to provide for more accurate prognosis and diagnosis, but also to test the relevance of in vitro or animal studies in a human neoplastic system. Such attributes will be developed in the future based on markers that are associated with tumor progression. Candidate markers include growth factors and cytokines and their receptors, adhesion molecules and their ligands, chemotactic and motility factors, immune response-related molecules, and tumor-associated proteases. Some of these markers that are represented in the transition from radial to vertical growth phase will be reviewed. The tumor progression model presented here has been of value in the development of more accurate prognostic models, and in the elucidation of mechanisms of the malignant phenotype in melanoma.

Control of transgenesis in higher cells: the procell transposon Tn10 TetR mRNA has several major hairpins and can be unstable in eucells

The TetR regulatory gene from the transposon Tn10 has some excellent characteristics for transgenic control in higher cells. However, we experienced severe problems with mRNA instability for this gene in eucells (CHO cells). This may be connected with the existence within the Tn10 TetR mRNA of several sizeable hairpins. They resemble canonical RNase E sites for mRNA destabilisation in procells and possibly also in eucells. Two of the hairpins also included sequences resembling eucell hnRNA polyadenylation or processing signals. The TetR counterpart from the plasmid RA1 appears to have less of the hairpin secondary structure; perhaps because of this, it did not present these mRNA instability problems in CHO cells, and it may prove a valuable alternative for transgene control in gene therapy and biotechnology.

Globin introns: ancient or modern?

Some globin introns appear to be ancestral features, others have been interpreted as later additions. However, these "anomalous" introns may be ancient relics of internal duplications within the original gene.

A model system for detection and isolation of a tumor cell surface antigen using antibody phage display

To establish a screening procedure for tumor cell-surface reactive Fabs, we used a model antigen/antibody system including the epidermal growth factor receptor (EGF-R) and the anti-EGF-R monoclonal antibody 425. The 425 Fab was displayed on the surface of M13 filamentous phage. In a screening assay for 425 phage binding to tumor cell surfaces, biotinylated 425-phage bound specifically to EGF-R-positive A431 epidermoid carcinoma cells and not to K562 non-expressor erythroleukemia cells. With a model library, the sensitivity of phage enrichment by phage binding to cell surfaces was one 425-phage in 20,000 unrelated phages after 4 rounds of panning on A431 cells. In a phage tissue screening assay, 425-phage, but not unrelated phage, bound specifically to melanoma cells expressing EGF-R. Epitope and idiotope specificity of 425-phage was demonstrated in phage competition assays, using as targets A431 cells and anti-idiotypic antibodies to monoclonal antibody 425, respectively. Finally, the EGF-R protein was directly isolated from A431 cell extracts, using biotinylated 425-phage. The data obtained with the 425 model library system demonstrate the usefulness of antibody phage display for the rapid identification and isolation of tumor or other disease-related cell surface antigens.

Combinatorial antibodies against human malignant melanoma

The general responsiveness of human melanoma to immunotherapy has been well established, but active immunotherapy of melanoma has been hampered by insufficient information on the immunogenicity of melanoma antigens in patients. We have attempted to identify melanoma-associated antigens recognized by patients' B cells using an antibody phage display approach. Antibody display on filamentous phages allows direct screening of cDNA libraries for expression of cell-surface-reactive antibodies, without the need for antibody production and purification using bacteria or eukaryotic cell systems. This approach was used to identify melanoma-associated cell-surface antigens recognized by patients' B cells. Antibodies produced by the B cells of a melanoma patient (in remission for > 7 years following periodic vaccination with allogeneic melanoma cell vaccine) were displayed as Fabs on the surfaces of filamentous phages. A library of 10(8) phages was absorbed to normal melanocytes, followed by phage binding to and elution from melanoma cells (human lymphocyte antigen nonmatched and vaccine melanoma cells). Phages were further selected for reactivities with tunicamycin-treated melanoma cells. These procedures resulted in a > 10(6)-fold enrichment of tumor-specific phages from the original phage library. One phage-Fab bound to melanoma cells, other tumor cells, and a few normal cells in cultured cell lines and in tissue sections.

Dysplastic nevi and other risk markers for melanoma

Risk markers for cancer are genetic or behavioral attributes that are statistically associated with increased incidence of cancer. Risk may be assessed either in case-control studies, or in cohort studies in which individuals with particular attributes are followed and cancer risk is determined by direct observation. Both of these methods have been used to determine the major risk markers for melanoma. The single most important risk marker is the presence on the skin of dysplastic nevi. Dysplastic nevi may be regarded as intermediate lesions of tumor progression, in that approximately 30% of melanomas arise in association with a precursor nevus, which is most commonly dysplastic. However, paradoxically, because they are vastly more numerous than melanoma, most dysplastic nevi are stable lesions that do not progress. Additional important melanoma risk factors include a family and/or personal history of melanoma. A third major category of risk markers includes indicators of acute and chronic exposure to the sun, including freckles, actinic skin damage, and a history of sunburn. Evaluation of these markers in oncological patients and their first-degree relatives can identify a population of individuals whose risk for melanoma ranges from several-fold to more than 100-fold greater than that of random population members. Efforts directed at early diagnosis in these individuals can result in recognition of melanomas in their early, curable stages.

A unique case of long-term survival in a male patient with malignant melanoma of the distal urethra

Primary malignant melanoma of the urethra in male patients is a rare entity, noted to have a dismal prognosis in recent reviews. No case of long-term disease-free survival in patients with primary malignant melanoma has been previously reported. We report the first such case, and review briefly the factors that could have contributed to our patient's long-term survival. We also illustrate the precursor lesion present six years prior to diagnosis.

Volunteer low-risk outpatient surgery for uninsured patients in San Francisco. The Ambulatory Surgery Access Coalition

OBJECTIVE

To provide uncompensated elective low-risk outpatient surgery for uninsured patients through a coalition of volunteer physicians, nurses, and hospitals.

DESIGN

Description of the process of establishing the Ambulatory Surgery Access Coalition (ASAC), the political and administrative obstacles encountered, and the clinical results of treatment of the first 25 patients in the pilot project.

SETTING

The ASAC includes the Kaiser Foundation Hospital, San Francisco, Calif, the University of California, San Francisco, the San Francisco General Hospital (SFGH), the San Francisco Department of Public Health, the San Francisco Consortium of Community Clinics, the Northern California Chapter of the American College of Surgeons, and the San Francisco Medical Society. A pilot program of uncompensated outpatient surgery was performed at the Kaiser Foundation Hospital.

PATIENTS

Twenty-nine patients were referred to the ASAC between January 1 and November 1, 1994. Twenty-six patients were judged to be candidates for surgery, and 25 patients met the criteria for the ASAC program. One patient was referred to SFGH for treatment because of a perceived increased risk for hospitalization after surgery.

RESULTS

Twenty-one patients underwent herniorrhaphy; three, excision of large inclusion cysts; and one, anal fistulotomy. Seventeen procedures were done under local anesthesia, seven under general anesthesia, and one under spinal anesthesia. None of the patients required hospital admission. No wound infections occurred.

CONCLUSION

The ASAC successfully provided uncompensated low-risk outpatient surgery to 25 low-income uninsured patients in San Francisco. The coalition hopes, first, to include other San Francisco hospitals and surgical specialties, and second, to serve as a model for other communities throughout the country.

Recognition and classification of clinically dysplastic nevi from photographs: a study of interobserver variation

The recognition of dysplastic nevi from photographs can aid in population surveys of nevi and in epidemiological studies of melanoma risk. The reproducibility of techniques for recognizing nevi as dysplastic or for scoring them according to the degree of dysplasia has not been measured. Using photographs of 300 nevi taken in the course of a case-control study of melanoma, we assessed the agreement among six clinicians in independently categorizing nevi as dysplastic and in grading the degree of dysplasia. On average, reviewers agreed with each other 77% of the time in classifying a nevus as dysplastic or normal. Pairwise agreement within one point on a six-point scale occurred 87% of the time on average. These results suggest that criteria for recognizing nevi as clinically dysplastic from photographs can be applied reproducibility.

Loco-regional nodal relapse in melanoma

Two-hundred and seven patients without evidence of disease following lymph node dissection (LND) were stratified into three groups: Group A, lymph node relapse within the site of prior LND; Group B, lymph node relapse in a different, but regional, lymph node group; Group C, no lymph node relapse. Decreased survival was noted in both Groups A and B versus Group C. Prognostic factors were identified as: (i) axial or subungal/volar (subvolar) location and the number of positive lymph nodes at initial LND for nodal relapse within the same lymph node group; (ii) male gender, axial/subvolar location, and the number of histologically positive lymph nodes at initial LND for nodal relapse in a different, but regional lymph node group; (iii) relapse within the initial LND site for a decreased survival. Six of 10 patients with both axial/subvolar primaries and four or more positive lymph nodes developed a relapse within the dissection site post-LND. These prognostic factors describe a subset of patients who would be candidates for postoperative adjuvant local/regional and systemic therapy trials.

Orbital involvement with desmoplastic melanoma

A 79-year-old woman developed an orbital mass five and a half years after excision of a cutaneous melanoma from the side of the nose. The initial orbital biopsy was interpreted histopathologically as a malignant fibrous histiocytoma, but special stains and electron microscopy showed it to be a desmoplastic malignant melanoma which had apparently spread to the orbit from the prior skin lesion by neurotropic mechanisms. The occurrence of a desmoplastic neurotropic melanoma in the orbit has not been previously recognised. The problems in the clinical and pathological diagnosis of this rare type of melanoma are discussed.

Staphylococcus aureus colonization and infection after discharge from a term newborn nursery

During a 6-month period, term infants underwent nasal and umbilical swabbing within 96 hours of delivery and again at 1 to 18 (mean 3.8) weeks after discharge. Swabs were inoculated onto horse blood agar and all S aureus isolates were phage typed. Two hundred three infants were enrolled and follow-up was obtained for 181 (89%). Thirty-two of 181 (17.6%) were initially colonized, of whom 12 (37.5%) were colonized on follow-up. Thirty-two of 181 became colonized subsequent to hospital discharge. No single phage type predominated. Twenty-five patients were diagnosed to have clinical illness--omphalitis (11), conjunctivitis (10), and pustulosis (5). Six of these were colonized with S aureus initially, although organisms of the same phage type were not recovered from cultures obtained at the time of clinical illness. There was no significant difference in the rate of infections in colonized (19%) versus non-colonized (12%) infants. In five patients where S aureus was recovered at the time of symptoms, all organisms were acquired subsequent to discharge. We conclude that nursery colonization with S aureus did not lead to clinical illness, and clinical illnesses previously ascribed to S aureus frequently occur in the absence of these bacteria.